Patient Care Agreement

This is a Patient Care Agreement between me and Advanced Women’s Health Institute on behalf of Michael L. Moore M.D.

Thank you for choosing Dr Moore. He will help you by conducting a thorough evaluation and then discuss all reasonable therapeutic options.

We need to make you aware of certain financial policies of the Institute.

Financial and Insurance Claims Policy

• A Current insurance card is required at each visit.
• We will need an email address to send your billing statements to.
• After completion of your visit a claim will be processed and submitted to the insurance company for payment. Our practice follows American College of OB/GYN correct coding guidelines.

A problem we frequently encounter is many insurance companies do not follow the correct coding guidelines and frequently choose to make their own rules to deny claims. This is not acceptable. It is all too common for an insurance company to send a statement saying the service is “included”, “not covered” or the reimbursement is $0.00. We will not accept this purposeful maneuver to avoid paying for services rendered. We will hold you responsible for all billable charges your insurance refuses to reimburse.

• All returned checks are subject to a $50.00 fee. 
• When charges are billed payment is expected within 30 days. A 2% late fee will be added to unpaid balances each month.
• In the event you are turned over to a collection agency, all collection fees, attorney fees and court costs will be added to your bill. 

Prescriptions and renewals

• Please have your pharmacy contact our office. We want to make sure the right prescription is called to the correct pharmacy. Please allow 48 hours for any prescription renewal. 
• Requests for prescriptions outside office hours are subject to a minimum $50.00 at $400/H service charge and are not covered by your insurance. 

Convenience services 

• Prescription requests without an office visit are charged $35 and are not covered by your insurance. 
• Calls outside office hours, which can sometimes avoid an ER visit are subject to a minimum $50.00 at $400/H service charge and are not covered by your insurance. 

Medical records requests 

• All medical records requests must be submitted in writing and signed by you. Medical records require 48 hours to send. They will be sent electronically per our green initiative. We refuse to print records that can be transferred electronically. If the practice you want them sent to refuses to provide an email address, we will send them to an email address you select. Email transfer of medical records is $15.00. Stat medical records transfer is available for a $50.00 fee.

Cancellation and no-show policy 

• If you need to cancel an appointment, please do so immediately. Cancellation less than 48 hours before your appointment or you do not show for your appointment will incur a $200.00 charge.

I have read the patient care agreement and understand and accept. I acknowledge that I will be billed for all services provided. Those not reimbursed by the insurance company that meet the correct coding guidelines will be my responsibility, and I agree to pay for them.